Maternal diet quality with child allergic and respiratory multimorbidity in the Elfe birth cohort

Evidence linking maternal diet during pregnancy to allergic or respiratory diseases in children remains sparse, and outcomes were mainly studied separately. We aim to investigate these associations by considering clusters of allergic and respiratory multimorbidity among 9679 mother–child pairs from the Elfe birth cohort. Maternal diet quality was evaluated using a food-based score (Diet Quality score), a nutrient-based score (PANDiet score) and food group intakes. Adjusted multinomial logistic regressions on allergic and respiratory multimorbidity clusters up to 5.5 years were performed. Child allergic and respiratory diseases were described through five clusters: “asymptomatic” (43%, reference), “early wheeze without asthma” (34%), “asthma only” (7%), “allergies without asthma” (7%), “multi-allergic” (9%). A higher PANDiet score and an increased legume consumption were associated with a reduced risk of belonging to the “early wheeze without asthma” cluster. A U-shaped relationship was observed between maternal fish consumption and the “allergies without asthma” cluster. To conclude, adequate nutrient intake during pregnancy was weakly associated with a lower risk of “early wheeze without asthma” in children. No association was found with food groups, considered jointly or separately, except for legumes and fish, suggesting that maternal adherence to nutritional guidelines might be beneficial for allergic and respiratory diseases prevention.


Data collection
Maternal diet quality Dietary intakes of the mothers during the last three months of pregnancy were collected during maternity stay with a validated semi-quantitative food frequency questionnaire including 125 items designed for French pregnant women 14 .Daily frequency was calculated and multiplied by portion size (in grams) to obtain daily food intakes.Nutritional intakes were obtained by crossing daily food intakes with the SU.VI.MAX food composition database 15 .Questionnaires with more than 10 missing items or with implausible daily energy intake (> 5072 kcal/ day (97th percentile) or < 933 kcal/day (3th percentile)) were considered invalid, and mothers were excluded from the study.
The quality of maternal diet during pregnancy was assessed with the Diet Quality score, the Probability of Adequate Nutrient intake Diet quality index (PANDiet score), and 11 food groups.The Diet Quality score 14 , based on French guidelines for pregnant women by food groups 16 , ranges from 0 to 18 points ; a higher score corresponding to a higher diet quality.The PANDiet score, previously adapted for pregnant women, ranges from 0 to 100 points ; a higher score reflecting a better nutritional adequacy, i.e. better adherence to French dietary reference values for pregnant women 17 .Scores were considered continuously, and food groups were considered as continuous, dichotomous or 3-class categorical variables according to French nutritional guidelines 16 (Supplementary Table S1).

Allergic and respiratory variables
Information on allergic and respiratory health of included children were collected by repeated phone interviews to parents.For this study, we used the following synthetic variables in children followed up to age 5.5: ever food allergy, ever itchy rash, ever night cough, ever wheezing, ever medication for asthma, ever medical consultation for asthma, ever allergic conjunctivitis, and allergic rhinitis at 5.5 years."Ever" outcomes were defined by at least one report of the mentioned health event during follow-up (Supplementary Table S2).

Study sample
Among the 18,329 mother-child pairs of the Elfe birth cohort, 57 were excluded after parents withdrew consent and one twin of two was randomly excluded to avoid family dependence (n = 287).Data for cluster construction were available for 11,246 children.When dietary information was missing or incorrectly completed, mothers were excluded (n = 1567).Finally, 9679 mother-child pairs were included in the main analyses (Fig. 1).

Statistical analysis
Included mothers were compared to excluded ones on baseline characteristics with Student t-test or Pearson chi-square test.
Allergic and respiratory multimorbidity clusters up to 5.5 years were determined using Latent Class Analysis (LCA) on the 8 synthetic variables mentioned before (ever food allergy, ever itchy rash, ever night cough, ever wheezing, ever medication for asthma, ever medical consultation for asthma, ever allergic conjunctivitis, allergic rhinitis).Solutions of 2 to 6 clusters were tested with 100 replications and 100,000 iterations.The optimal number of clusters was selected through Bayesian Information Criterion (BIC) minimization and interpretability.
Separate multinomial logistic regressions were run for each dietary variable in unadjusted and adjusted analyses.The potential confounders were selected through a directed acyclic graph (Supplementary Figure S1).Models were then adjusted for maternal characteristics (age, education level, household income, living area, region, migration status, smoking status during pregnancy, pre-pregnancy body mass index, physical activity during pregnancy, parity and total energy intake), child characteristics (family history of atopy (i.e.asthma, allergic rhinitis, eczema in parents or siblings), sex), and variables related to study design (period of enrolment, corresponding to season of birth, size of maternity unit).No interaction was found between dietary variables and family history of atopy, child's sex, or maternal smoking status during pregnancy.For multiple categorical variables, p-trend or quadratic trend p-values were calculated.Multiple imputation on missing covariates was performed (Supplementary Table S3).Analyses in the imputed dataset are presented as main analyses and were replicated in the complete-case sample to assess consistency.
To deal with potential selection and attrition bias, sensitivity analyses were performed based on weighted data.Calculation of weights included the inclusion procedure, biases related to non-consent or attrition 18 and calibration on margins from the state register's statistical data and the 2010 French National Perinatal study 19 on region, age, migration status, education level, marital status and primiparity.Results on food groups were corrected for multiple testing using the False Discovery Rate procedure 20 , a q-value < 0.1 was considered significant.
All analyses were performed with SAS version 9.4 (SAS Institute Inc, Cary, NC, USA), except LCA performed with R software version 4.1.2(R Foundation for Statistical Computing, Vienna, Austria).

Sample characteristics
Included mother and child pairs differed from excluded pairs particularly in terms of age, socioeconomic level, migration status and family history of atopy (Table 1).In our study population the Diet Quality Score ranges between 8.8 and 17.0 points, and the PANDiet score between 23.7 and 88.1 points; maternal diet during pregnancy is described in Table 2 and Supplementary Table S4.

Identification of allergic and respiratory clusters
A five-class solution was identified, clusters were labelled according to their allergic and respiratory characteristics (Table 3; Supplementary Table S5): • "asymptomatic" (43% of children): low prevalence of allergic and respiratory disorders.
• "early wheeze without asthma" (34% of children): high prevalence of respiratory symptoms without medical consultation for asthma.Detailed data showed a high prevalence of wheezing, medication for asthma and www.nature.com/scientificreports/night cough until 2 years old which lowered afterwards (50.7% children with reported wheezing at 1 year and 18.5% at 3.5 years).• "asthma only" (7% of children): high prevalence of respiratory symptoms, but low prevalence of food allergy, rash and allergic conjunctivitis.• "allergies without asthma" (7% of children): high prevalence of food allergies, rash, allergic conjunctivitis and rhinitis, but low prevalence of asthma and wheezing after 1 year.• "multi-allergic" (9% of children): high prevalence of multiple allergic and respiratory symptoms.

Maternal diet and allergic and respiratory multimorbidity clusters
The "asymptomatic" cluster was the reference group for all analyses.
Overall diet quality: No association was found between an increment of one unit of the Diet Quality Score and the allergic and respiratory multimorbidity clusters in both unadjusted and adjusted multinomial logistic regressions (Table 4).A borderline association was observed between a 10-point increase of the PANDiet score and a lower risk of belonging to the "early wheeze without asthma" cluster (adjusted oddsratio; aOR [95%CI] = 0.95 [0.90;1.00]).Such trend was also observed in the analyses based on complete cases (aOR [95%CI] = 0.95 [0.90;1.01];Supplementary Table S6) and in the weighted analyses (aOR [95%CI] = 0.94 [0.87;1.00];Supplementary Table S7).
Food groups intake: Frequent maternal consumption of legumes was associated with a lower risk of belonging to the "early wheeze without asthma" cluster (aORs [95%CI] = 0.86 [0.75;0.98]and 0.82 [0.64;1.04]for legume consumption 1-4 times/month and > 1 times/week vs. < 1 time/month respectively ; p for trend = 0.005) (Table 5).A U-shaped relationship between maternal fish consumption and a higher risk of belonging to the "allergies Table 1.Characteristics of included and excluded mother-child pairs.BMI: body mass index ; SD: standard deviation.† by consumption unit ; ¶ p-value for comparison between included and excluded samples using Student t tests for continuous variables and chi-square tests for categorical variables.

Excluded sample n = 8650
Included sample n = 9679 None of the associations remained significant after correction for multiple testing (Supplementary Table S8).www.nature.com/scientificreports/

p-value ¶ Missing % (n) % (n) or mean ± SD Missing % (n) % (n) or mean ± SD
In the analyses on complete cases, results were not substantially changed (Supplementary Table S6).In the weighted sample analyses, effect estimates for legume and fish consumption remained similar, but no longer significant.Furthermore, starch and grain consumption was related to a lower risk of belonging to the "multiallergic" cluster and a higher consumption of vegetables was related to a higher risk of belonging to the "allergies without asthma" cluster (Supplementary Table S7).

Discussion
In this study, allergic and respiratory multimorbidity in children up to age 5.5 was described with five clusters: "asymptomatic", "early wheeze without asthma", "asthma only", "allergies without asthma", and "multi-allergic".Overall maternal diet quality during pregnancy was weakly associated with allergic and respiratory multimorbidity clusters in children.A higher consumption of legumes during pregnancy was associated with a lower risk of belonging to the "early wheeze without asthma" cluster in children compared to the "asymptomatic" cluster, and a U-shape association between maternal fish consumption and the "allergies without asthma" cluster was found.
A borderline association between a better nutritional adequacy during pregnancy and a lower risk of early wheeze without asthma in children was observed in our study.In most prior studies, no association was reported for maternal diet quality during pregnancy with allergic and respiratory diseases considered separately [8][9][10][11]21,22 or jointly 7 . Howevr, in an observational study with a 10-year follow-up a higher diet quality was associated with a lower risk of asthma in children 5 . I a pooled analysis from seven European birth cohorts, a very low dietary quality was associated with a higher risk of preschool wheezing 6 , and in two prospective longitudinal studies a healthier diet was associated with a higher risk of eczema at age 1 23 and 7-9 years 24 , respectively.
In our study, consumption of legumes during pregnancy was associated with a lower risk of early wheeze without asthma in children and was not associated with the other clusters.The association was only significant for moderate consumption (1-4 times/month), and not for the recommended frequency of more than once a week.This may be explained by a lack of statistical power, as only 4% of the population reporting a pluri-weekly consumption of legumes as suggested by the linear trend observed and the unadjusted results.In another cohort, we also highlighted an association between low legume consumption and a higher likelihood of belonging to the "multi-allergic" cluster 7 .In other studies, legumes were associated with a lower risk of eczema 25 in children, and a borderline association was found with a lower risk of persistent wheeze 26 , but most studies did not report associations with respiratory or allergic symptoms [27][28][29][30][31] .Fibres contained in legumes may explain the lower risks observed.It has been shown that fibres can modify the composition of gut microbiota and protect against airway allergic inflammation 32 .Additionally, maternal transmission likely participates in the establishment of gut microbiota in children 33 .Their potential anti-inflammatory effect may favour the healthy development of the immune system, making children less vulnerable to oxidative stress 6 .
In our study, both a lower and a higher than recommended maternal consumption of fish or shellfish were associated with a higher risk of allergies without asthma in children suggesting a complex interaction between potential beneficial (long-chain polyunsaturated fatty acids) and deleterious (food chemicals) components contained in fish 34 .That association was not found in our previous study on clusters of allergic and respiratory disorders 7 , may be due to a lack of statistical power.In studies considering allergies separately, maternal sea product consumption was associated with a higher risk of eczema 35 , atopy 9 or food allergy in children 27,36 , but also with a lower risk of eczema [37][38][39][40] , allergic rhinitis 37 or food allergy 41 .A systematic review with a meta-analysis of prospective observational studies reported no association between maternal fish consumption and eczema or wheezing 42 .
Using data from the Elfe birth cohort confers several strengths to our study.The large sample size and the detailed data collected in the Elfe study allowed adjustment on numerous potential confounders, even if residual confounding cannot be excluded.Although comparison between included and excluded participants suggested a selection bias, the design of the Elfe study enables the calculation of weights extending the validity of our results.In weighted analyses, no difference was observed for diet quality scores, but associations were Table 4. Associations of maternal diet quality scores during pregnancy with allergic and respiratory multimorbidity clusters in children (n = 9679).Cluster of reference: "asymptomatic".Results with p-value < 0.05 are in bold text.OR [95%CI] from multinomial logistic regressions.OR, odds ratio; CI, confidence interval.Each dietary score was considered in a separate model.Cluster of reference: "asymptomatic".† Models are adjusted for maternal characteristics (age at delivery, education level, household income, migration status, smoking status during pregnancy, pre-pregnancy body mass index (BMI), physical activity during pregnancy, number of older children, living area (urban/rural), region and total energy intake), child characteristics (sex and family history of atopy), and study design characteristic (period of enrolment, size of maternity unit).www.nature.com/scientificreports/reinforced for starch and grains and vegetables and attenuated for fish and legumes.These discrepancies might be explained by a differential influence of selection bias according to food groups.Maternal dietary exposures were self-reported after delivery which may lead to measurement errors.However, the questionnaire was validated 14 and focused on the last months of pregnancy to limit recall bias.Our results should not be generalised to the overall pregnancy, even if few changes in dietary intakes have been observed elsewhere between early and late pregnancy 43 .We addressed diet quality during pregnancy with a food-group-based and a nutrient-based score, two complementary approaches, and to identify the possible role of specific food groups, we investigated individual food groups.However, the scores were developed for overall health, not specifically for allergic and respiratory diseases, so the weak associations we found do not mean that maternal diet quality is not important.Breastfeeding and early introduction of food allergens have been associated with the risk of developing atopic diseases 44,45 .However, they have not been considered in our models as potential confounders because they are posterior to maternal diet.Further adjustment for these factors did not substantially change our results (data not shown).
The questionnaire used for allergic and respiratory symptoms was not validated, but is derived from the International Study of Asthma and Allergy in Childhood (ISAAC) questionnaire 46 ; misclassification bias cannot be excluded although the prospective design limits recall bias.We accounted for the complex inter-relations between allergic and respiratory diseases in children by constructing unsupervised multimorbidity clusters including most common allergic and respiratory symptoms.Lung function was not available and, our clusters did not provide information on disease course which could be further investigated with longitudinal approaches.In the present study, we identified four clusters similar to those in our previous study performed on a smaller sample size 7 .We also identified an additional cluster of "early wheeze without asthma", which could correspond to transient wheezing not leading to asthma and which might result from infections since night cough and wheezing are not specific to asthma.This analysis, based on a larger cohort, supports our previous results on diet quality and legumes and provides new elements on fish consumption.
To conclude, in a large birth cohort, allergic and respiratory multimorbidity in children was described with five clusters.While the overall maternal diet quality during pregnancy was weakly associated with allergic and respiratory multimorbidity, a higher legume consumption was associated with reduced risk of early wheeze not leading to asthma in children, and a U-shape relationship between maternal fish consumption and the risk of allergic diseases other than asthma was found.Further studies are needed to confirm if adherence to nutritional guidelines during pregnancy for legumes and fish is beneficial for the prevention of allergic and respiratory diseases in children.

Figure 1 .
Figure 1.Flowchart of the study population.

Table 3 .
Prevalence of allergic and respiratory diseases in children up to 5.5 years in the allergic and respiratory multimorbidity clusters (n = 11,246).Values are in % (n) and are the prevalence of the variable included in the cluster construction.

Table 5 .
Associations of maternal food groups consumption with allergic and respiratory multimorbidity clusters in children (n = 9679).Cluster of reference: "asymptomatic".Results with p-value < 0.05 are in bold text.OR [95%CI] from multinomial logistic regressions.OR, odds ratio; CI, confidence interval.Each dietary exposure was considered in a separate model. †